AAPC CPC - Certified Professional Coder (CPC) Exam
A 30-year-old patient with a scalp defect is having plastic surgery to insert tissue expanders. The provider inserts the implants, closes the skin, and increases the volume of the expanders by injecting saline solution. Tissue is expanded until a satisfactory aesthetic outcome is obtained to repair the scalp defect.
What CPT® code is reported?
A patient underwent a cystourethroscopy with a pyeloscopy using lithotripsy to break up the ureteral calculus. An indwelling stent was also inserted during the same operative session on the same side. This service was performed in the outpatient hospital surgery center.
What CPT® coding reported?
A patient undergoes coronary angiography for chest pain. Coronary arteries are normal, and CAD is ruled out.
What CPT® and ICD-10-CM codes are reported?
(What modifier is appended to indicate that during thepostoperative period, a procedure is performed that wasplanned,more extensivethan the original procedure, or done fortherapeutic reasons?)
(A dermatologist excises abasal celllesion from an area of thescalp, measuring3.7 cm. This is closed with alayered repair. What CPT® and ICD-10-CM codes are reported?)
(Full Case:Preoperative diagnosis:Low back pain; possible spinal stenosis L3–4.Postoperative diagnosis:No evidence of discogenic pathology or spinal stenosis at L3–4; normal discography L3–4.Procedure:Awake discography and injection, L3–4.Anesthesia:IV narcotic with reversal and local; propofol given transiently, then patient alert/responsive for pain response during injection.Technique:Patient to OR; right decubitus; sterile prep/drape; C-arm used to mark entry; local ethyl chloride + 1% Xylocaine; docking needle placed posterolateral at L3–4 under AP/lateral; inner needle advanced to disc nucleus center; contrast injected while monitoring patient response; normal bilocular pattern; 1.5 cc volume; no pain with pressurization.Documentation:No videotape; plain films available; post-discography CT planned/reviewed for other causes.Question:What CPT® and ICD-10-CM coding is reported?)
An elderly patient comes into the emergency department (ED) with shortness of breath. An ECG is performed The final diagnosis at discharge is impending myocardial infarction.
According to ICD-10-CM guidelines, how is this reported?
A 45-year-old has a dislocated patella in the left knee after a car accident. She taken to the hospital by EMS for surgical treatment. In the surgery suite, the patient is placed under general anesthesia. After being prepped and draped, the surgeon makes an incision above the knee joint in front of the patella. Dissection is carried through soft tissue and reaching the patella in attempt to reduce the dislocation. When the patella is exposed, it is severely damaged due to cartilage breakdown. The tendon is dissected and using a saw the entire patella is freed and removed. The tendon sheath is closed with sutures.
What procedure code is reported for this surgery?
(An orthopedic surgeon evaluated a patient in the emergency room two months after a surgical repair of a right radius and ulnar shaft fracture. After reinjury, imaging shows a displaced proximal fixation screw andmalunion of only the radial shaft. The same surgeon performs surgery to repair the malunion using a graft from the hip. What CPT® and diagnosis codes are reported?)
An ED provider evaluates a patient with NSTEMI, consults cardiology, and the patient is admitted for PCI.
What E/M service and ICD-10-CM coding is reported by the ED provider?
